Surviving and THRIVE-ing the difficult airway: gaining calm, control, and time during an emergent tracheostomy.

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A patient with recurrent squamous cell carcinoma of the larynx required endotracheal intubation for radical laryngectomy. His limited neck extension due to prior radiation therapy made direct laryngoscopy ill advised. Nasopharyngeal fiberoptic exam five days prior suggested that an awake tracheostomy was not indicated. After discussion with the surgeons, a plan was made to induce anesthesia, place a supraglottic airway (SGA), and then perform SGA-endotracheal tube (ETT) exchange using a flexible fiberoptic scope (FFS). Once the SGA was seated, it became apparent during FFS exam that the patient's disease had progressed to the degree that only one third of the glottic opening could be visualized due to increased tumor obstruction and edema. Two unsuccessful attempts to pass FFS through the vocal cords led to trauma and bleeding from the friable tumor tissue, resulting in difficulty with ventilation via the SGA. SGA was removed, and rescue insufflation of humidified high-flow nasal oxygen (HFNO) using the Optiflow system (Fisher & Paykel Healthcare, Auckland, New Zealand) was initiated, while the surgeons prepared for an emergent tracheostomy, which proved to be technically challenging. During that time, the patient was apneic under general anesthesia and remained hemodynamically stable with an oxygen saturation (SpO2) of 100%. The use of HFNO (Transnasal Rapid Insufflation Ventilatory Exchange, THRIVE) can provide reliable rescue oxygenation during airway emergencies, allowing for effective front of neck surgical access.

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